Englewood Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Englewood Health & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Aug 16, 2024

  Based on observation and interview, the facility failed to ensure residents' privacy and dignity by asking permission prior to entering residents' room for 4 of 13 residents reviewed. (Resident 18, Resident 17, Resident 34, Resident 40). Findings include: 1. During a medication administration observation on 8/14/24 at 7:38 AM, RN 3 entered Resident 18's room without knocking, announcing herself, or asking permission to enter. She proceeded to turn on his light and explain care she was to provide. Resident 18's diagnoses included stroke, heart disease, and dysphagia. Resident 18's BIMS (Brief Interview of Mental Status) most recent 7/17/24 score of 2 indicated a severe mental status deficit. 2. […]

• No harm, potential for more than minimal, patternF602Sep 6, 2023

  During interview and record review the facility failed to ensure narcotic medications were handled securely for 4 of 4 residents reviewed. (Resident B, Resident C, Resident D and Resident E) Findings include: A review on 9/5/2023 at 12:10 P.M., of a facility's State Reported Incident provided by the Administrator in Training (AIT) on 9/5/2023 at 11:24 AM indicated on 8/30/2023 at 4:01 PM, an unnamed nurse reported the narcotic count sheet and the narcotic medication on hand did not match for Resident B. An investigation was initiated immediately, included interviews with nurses involved and reviewing the camera footage. The report indicated LPN (Licensed Practical Nurse) 1 was suspended pending the investigation. […]

• No harm, potential for more than minimal, patternF812Jul 20, 2023

  Based on observation, and interview the facility failed to ensure sanitary practices were observed in the kitchen. 53 of 56 residents to residing in the facility ate food prepared in the kitchen. Findings include: During an observation on, 7/17/23 at 9:03AM, noted floor was slippery. The floor had an oily feel. The area with the slippery, oily feel was from in front of the oven to just beyond the stove top range. The top of the oven had trays and multiple crumbs. The crumbs varied in size and color (yellow, brown, and black) There were 2 hamburgers in the refrigerator with cellophane covering. There was no date labeling on the hamburgers. The dietary aide was unable to determine when the hamburgers were prepared. […]

• No harm, potential for more than minimal, isolatedF580Apr 18, 2023

  Based on record review and interview, the facility failed to ensure family and hospice services were notified of a condition change for 1 of 3 records reviewed (Resident C). During an interview on 4/18/23 at 9:35 AM, Resident C's Power of Attorney (POA indicated she received a call at 5:15 AM on 4/6/23 informing her Resident C had passed away. Upon arrival at the facility, staff informed her Resident C had vomited and received medication for vomiting the evening before. The POA indicated the facility had not contacted her about a condition change. […]

• No harm, potential for more than minimal, isolatedF686Sep 13, 2022

  Based on interview, and record review, the facility failed to ensure wound care and assessments for pressure wounds were completed as ordered for 1 of 2 residents reviewed. (Resident T) Resident T's record was reviewed on 9/8/22 10:49 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident T's Quarterly Minimum Data Set Assessment, dated 6/24/22, indicated a brief interview for mental status score of 13 (cognitively intact). Activity of daily living section indicated the resident required extensive assistance with bed mobility, locomotion on and off unit, toileting, and personal hygiene. Resident T required total assistance with transfers and bathing, had an indwelling catheter and was always incontinent of bowel. […]